Provider Demographics
NPI:1114348240
Name:WIESELTIER, EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:WIESELTIER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 BROADWAY STE G
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5304
Mailing Address - Country:US
Mailing Address - Phone:619-425-8212
Mailing Address - Fax:619-425-8337
Practice Address - Street 1:542 BROADWAY STE G
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5304
Practice Address - Country:US
Practice Address - Phone:619-425-8212
Practice Address - Fax:619-425-8337
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO3586390200000X
CA20A15647208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program